Antimicrobial%20Stewardship%20in%20Long%20Term%20Care

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Antimicrobial Stewardship in Long Term Care

• Marianne Pavia, MS, BS, MT(ASCP), CLS,CIC

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Learning Objectives

• Understand the burden of infection in LTC as
  related to the characteristics of the residents
  and the capabilities of the facility.
• Describe the challenges and patterns of use of
  antibiotics in a LTCF.
• Develop and apply the minimum criteria for
  initiating antimicrobial therapy in LTC.
• Understand the uniqueness of a facility in regard
  to developing strategies for a stewardship
  program.
• Apply CDC Campaign to prevent antimicrobial
  resistance among LTC residents.

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Long Term Care Characteristics

• 1.7 million residents in LTC
• Mean age 80
• Decreased
• Immune function
• Swallowing/ chewing
• Skin integrity
• Mobility
• Bowel and bladder control
• Increased
• Acuity
• Medications
• Dementia/depression/apathy

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Burden of Infection in LTC

• 15,000 LTCFs in United States
• Infection prevalence rate 5.3 (single day
  survey)
• Infection incidence rate 3.6-5.2/1000 resident
  days
• Examples
• UTI
• Lower respiratory, including pneumonia
• Skin and soft tissue
• Gastroenteritis

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Burden of Infection in LTC

• Higher incidence of invasive MRSA
• MDRO more severe infections, hospitalizations,
  risk of death, cost of care
• 12 month Rhode Island study
• 72 inappropriate Ab, according to guidelines
• 67 longer than recommended duration
• Adverse drug event risk
• Increased incidence of Cdiff
• Gerwitz JH, Field TS, Harrold LR. Incidence and
  preventability of adverse drugevents among older
  persons in the ambulatory setting. JAMA
  2003289110711.

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Challenges with Antimicrobial Use in LTC

• Suspected UTIs account for 30-60 of antibiotic
  use due to diagnostic challenges
• Clinical providers are off-site
• Assessments communicated by front-line staff
• Limited diagnostic testing (laboratory and
  radiology)
• Off-site testing results in delays in specimen
  receiving, processing and results

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Patterns of Antimicrobial Use in LTC

• 47-80 residents exposed to one antibiotic
  course yearly.
• Variability due to
• Provider prescribing habits
• Types of residents
• Types of resident services- i.e. pulmonary team
• Estimate of inappropriate use of Ab varies upon
  definition
• between 25-75

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Loeb Minimum Criteria (LMC)

• Created in 2000, updated in 2005
• Minimum criteria of symptoms that should be
  present before initiating antimicrobial therapy
• Developed to
• Decrease inappropriate use of Ab without evidence
  of infection
• Decrease the overuse of newer, broad spectrum Ab
• Guide rational assessment of infection
• Proposed to improve Ab use
• Effect of a multifaceted intervention on number
  of antimicrobial prescriptions for suspected
  urinary tract infections in residents of nursing
  homes cluster randomized controlled trial. Loeb
  M1, Brazil K, Lohfeld L, McGeer A, Simor A,
  Stevenson K, Zoutman D, Smith S, Liu X, Walter
  SD.

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Loeb Minimum Criteria
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Urine Culture Results Algorithm
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Intervention LTC with Loeb Minimum Criteria

• Sent algorithms to physicians with written
  explanatory notes
• Mounted at nursing stations
• Presented 6 case scenarios to staff
• Nursing completed log of symptoms
• Four week training period

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LMC
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Successful Interventions with LMC in LTC

• Still new to LTC implementation but
• 30 reduction in Ab use and decreased Cdiff in
  one institution that used ID consultant
• 20 decrease in Ab that were adherent to
  guidelines from educational material ( no
  decrease in control group)
• Jump RL, Olds DM, Seifi N, et al. Effective
  antimicrobial stewardship in a longterm care
  facility through an infectious disease
  consultation service keeping a LID on antibiotic
  use. Infect Control Hosp Epidemiol
  201233(12)118592.
• Monette J, Miller MA, Monette M, et al. Effect
  of an educational intervention on optimizing
  antibiotic prescribing in long-term care
  facilities. J Am Geriatr Soc 20075512315.

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Case Study

• 92 yo female with stage 5 Alzheimers in LTC for
  severe knee arthritis, which has prevented her
  for walking for the past year. In addition, she
  suffers from depression and advanced glaucoma.
  Staff calls on-call MD noting dark and
  concentrated urine. Resident is also more
  confused but afebrile with normal vitals and no
  catheter in place. Nursing staff asks MD for a
  urine and he orders UA and culture.
• Two days later, primary attending is called with
  urine results not knowing the clinical situation
  present on ordering. Patient is now stable and no
  fever or urinary symptoms.
• UA mod pyuria and 1 nitrites
• Cx- 100 K GNR

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Case Study Questions

• Are there minimal criteria that should be
  considered prior to initiating antibiotic
  treatment for suspected UTI in a LTC resident?
• Is there a potential for harm when ordering urine
  tests for LTC residents in the setting on
  non-specific symptoms?
• Is withholding an antibiotic in the presence of
  nonspecific symptoms the same as failure to
  treat?
• What is the role of the facilitys ICP and
  medical director in reducing over-diagnosis and
  treatment of UTI?

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Question 1 Are there minimal criteria that
should be considered prior to initiating
antibiotic treatment for suspected UTI in a LTC
resident?

• The McGreer Criteria
• Surveillance purposes, highly specific for
  reliable bench marching
• Often determined retrospectively following full
  assessment
• Not the standard for initiating antibiotics

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Question 2. Is there a potential for harm when
ordering urine tests for LTC residents in the
setting on non-specific symptoms?

• Asymptomatic Bacteriuria- prevalence rate of
  15-50 in LTC
• Positive UA and culture in LTC regardless of
  presence of UTI
• Over treating
• Adverse drug reactions
• Increase Cdiff rates
• Increase in MDROs

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Question 2. Is there a potential for harm when
ordering urine tests for LTC residents in the
setting on non-specific symptoms?

• Urine tests drive decisions
• Intervention is an algorithm to reduce
  unnecessary testing and treatment
• Trials decrease Ab use with no negative outcomes

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Question 3. Is withholding an antibiotic in
the presence of nonspecific symptoms the same as
failure to treat?

• MD expected to take action
• Worry about missing an infection, delayed
  treatment or not meeting the familys expectation
• Observing and monitoring is taking action
• Watchful waiting- a cornerstone of clinical
  practice

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Question 4. What is the role of the facilitys
ICP and medical director in reducing
over-diagnosis and treatment of UTI?

• QAPI target- safety and liability risks, costs
  and impact residents quality of life.
• Establish minimum criteria for culturing
• Communicate findings from antibiogram
• Support tools for reporting change in resident
  condition (SBAR)
• Educate resident and family as well as staff and
  MD

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Infectious Disease Society of America (IDSA)
Guidelines

• 2008 updates to Clinical Practice Guideline for
  the Evaluation of Fever and Infection in Older
  Adult Residents of Long-Term Care Facilities
• Felt LMC too focused on fever
• Fever is absent in more than one-half of LTCF
  residents with serious infection
• Focuses on elderly with multiple chronic co
  morbidities and functional disabilities
• Resources are typically available to evaluate
  suspected infection
• What clinical evaluation should be performed

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Implementing Antimicrobial Stewardship
Interventions

• There is no one-size-fits-all approach.
• Understand what the problem areas are at your
  institution
• Determine what resources are available or may
  become available
• Select stewardship strategies that best address
  the problems while accounting for the resources
• Show off your success (or explain why success was
  not possible)
• Use your success to secure more resources to
  address more problem areas.

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Core Elements for Antimicrobial Stewardship
Program

• Leadership commitment
• Accountability for improvement
• Need drug expertise
• Implementing action through targeted policies and
  guidelines
• Tracking and reporting to staff on prescribing
  and resistance
• Identifying key participants and ASP champions
  and offer education

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Prescriptions

• Physicians discuss with a stewardship team member
  before prescribing
• is usage appropriate
• may delay initiating therapy
• Post-prescription review
• Best 48-72 hours or once a week

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St. Marys Hospital for ChildrenAntimicrobial
Stewardship Program
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SMH Stewardship Program

• Leadership commitment- driven by CEO
• Accountability for improvement- QAPI for medicine
• Tracking and reporting to staff on prescribing
  and resistance
• Implementing modified LMC/IDSA policies and
  guidelines for our population
• 100 children- 60 trach, 10 vented, 10 short
  gut w/TPN

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Cumulative Antibiogram

• The primary use is for the selection of
  appropriate empiric therapy.
• The use will result in tools to track antibiotic
  resistance as well as to assist the physician in
  making empiric antibiotic selections.
• Limited bacteriology cultures ordered
• 2014 created MDROs

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SMH Stewardship Program

• Jan 2014
• Organized ASP Committee- Director of Pharmacy,
  Medical Director, Nursing Leadership, IC
• Reviewed Ab use retrospectively monthly
• Epic fail
• April 2014
• Reorganized, low hanging fruit

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SMH Stewardship ProgramConjunctivitis Criteria

• Not be due to allergy or trauma to the
  conjunctiva and one of the following
• Pus from one or both eyes
• New or increased conjunctival redness with or
  without itching or pain
• If meets criteria
• Bacterial eye culture
• Ab treatment initiated- Fluoroquinolone drops
• Ab discontinued in culture is negative

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SMH Stewardship ProgramConjunctivitis
Resident Eye Cult Date Results Growth Treatment
Ana 8/30/14 9/2/14 Rare CNS, Rare Coryn sp Tobradex 8/30-9/2
Joseph 8/31/14 9/4/14 Rare Haem influenza Oflaxacin 8/31-9/07
Jason 9/4/14 9/10/14 Mod CNS Tobrex 9/5-9/10
Austin 9/12/14 9/16/14 Few Prot mirabilis, rare MSSA Oflaxacin 9/12-9/19
Adam 9/18/14 9/21/14 Many Haem influenza Cipro 9/19-9/26
Stephanie 10/2/14 10/4/14 Many Moraxella catarrhalis Cipro 10/2-10/9
Jordan 10/10/14 10/13/14 Few CNS, Few AHS Cipro 10/10-10/17
3/7 or 43 - not significant growth. Discontinue
Abs
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SMH Stewardship ProgramRespiratory Viral Criteria

• A case definition as follows
• Fever 100.5ºF above AND least ONE of the
  following
• Runny nose
• Change in sputum
• Shortness of breath
• Wheezing
• New or increased dry cough
• Criteria met
• RVP ordered
• Ab treatment considered if RVP is negative and
  symptoms present

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SMH Stewardship Program Tracheitis

• Uncommon infectious cause of acute upper airway
  obstruction except at SMH
• Work in progress
• Need criteria
• Many returns from ACF on Abs for tracheitis
  even if RVP is positive
• Being treated with Ab that are inappropriate
• Stop/question treatment
• Tobi nebs

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 Topical Antibacterial Products
Agent Uses Comment
Bactraban mupirocin impetigo (ointment) localized minor skin infections (cream) nasal formulation indicated to eradicate nasal colonization of MRSA available in ointment, cream, and nasal ointment formulations relatively expensive available by prescription
bacitracin localized minor skin infections Inexpensive available OTC

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SMH Stewardship Program Future Work Needed

• Attention to transmission and treatment between
  LTCFs and ACF serving the same communities
• Increased implementation of guidelines for
  culturing and treatment
• Better documentation
• CLABSI de-escalating treatment
• Approval for specific antimicrobials

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http//www.kliinikum.ee/infektsioonikontrolliteeni
stus/doc/oppematerjalid/longterm.pdf
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Prevent Infection

• Step 1. Vaccinate- staff and residents
• Step 2. Prevent conditions that lead to infection
• aspiration, pressure ulcers, dehydration
• Step 3. Get the unnecessary devices out
• Insert only when essential
• Minimize duration and reassess regularly
• Use proper insertion and care protocols
• Remove when no long necessary

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Diagnose and Treat Infection Effectively

• Step 4. Use established criteria for diagnosis
• Target empiric therapy to likely pathogens
• Target definitive therapy to known pathogens
• Obtain appropriate cultures and interpret results
  with care
• Consider Cdiff in patients with diarrhea and
  antibiotic exposure
• Step 5. Use local resources
• Consult infectious disease experts
• Know what is going on in your local and regional
  area
• Get previous updates and labs from transfer
  residents

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Use Antimicrobials Wisely

• Step 6. Know when to say NO
• Minimize use of broad-spectrum antibiotics
• Avoid long-term prophylaxis
• Monitor antibiotic use
• Step 7. Treat Infection, not colonization or
  contamination
• Re-evaluate the need for Abs after 48-72 hours
• Do not treat asymptomatic bacteriuria
• Step 8. Stop antimicrobial treatment
• When cultures are negative and infection unlikely
• When infection has resolved

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Prevent Transmission

• Step 9. Isolate the pathogen-standard and
  transmission-based precautions
• Step 10. Break the chain of infection
• Step 11. Perform hand hygiene
• Step 12. Identify residents with MDROs
• Identify both new admissions and existing
  residents with MDROs
• Follow standard precautions for MDRO management

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References

1. IDSA Guideline Kevin P. High, Suzanne F.
   Bradley, Stefan Gravenstein, David R. Mehr,
   Vincent J. Quagliarello, Chesley Richards, and
   Thomas T. Yoshikawa Clinical Practice Guideline
   for the Evaluation of Fever and Infection in
   Older Adult Residents of Long-Term Care
   Facilities 2008 Update by the Infectious
   Diseases Society of America Clin Infect Dis.
   (2009) 48 (2) 149-171 doi10.1086/595683
2. J Am Geriatr Soc. 2007 Aug55(8)1231-5.Effect of
   an educational intervention on optimizing
   antibiotic prescribing in long-term care
   facilities. Monette J1, Miller MA, Monette M,
   Laurier C, Boivin JF, Sourial N, Le Cruguel JP,
   Vandal A, Cotton-Montpetit M.
3. Jump RL, Olds DM, Seifi N, et al. Effective
   antimicrobial stewardship in a long term care
   facility through an infectious disease
   consultation service keeping a LID on antibiotic
   use. Infect Control Hosp Epidemiol
   201233(12)118592.
4. Monette J, Miller MA, Monette M, et al. Effect of
   an educational intervention on optimizing
   antibiotic prescribing in long-term care
   facilities. J Am Geriatr Soc 20075512315.
5. Stone ND, Rhee SM. Antimicrobial stewardship in
   long-term care facilities. Infect Dis Clin North
   Am, 2014 Jun 28(2)237-46. doi
   10.1016/j.idc.2014.01.001

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Questions/Comments